Veterinary Forum | August 2009

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NEWS VACCINE PROTOCOLS: AN IMPORTANT PART OF EVERY PRACTICE

FORUM ®

REAL PRACTICE. REAL MEDICINE. REAL NEWS.

What happened to

‘recession-proof?’

Biting Be Gone Thoracic Radiology: Pulmonary Patterns A Familiar Diagnosis Visit us at www.ForumVet.com

AUGUST 2009 • VOL. 26, NO. 8

veterinary

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EDITORIAL STAFF Tracey L. Giannouris, MA, Executive Editor 267-685-2447 | tgiannouris@vetlearn.com Paul Basilio, Associate Editor 267-685-2421 | pbasilio@vetlearn.com Allyson Corcoran, Editorial Assistant 267-685-2490 | acorcoran@vetlearn.com VETERINARY ADVISER Dorothy Normile, VMD, Chief Medical Officer SALES AND MARKETING Boyd Shearon, Account Manager 913-322-1643 | 215-287-7871 bshearon@vetlearn.com Joanne Carson, National Account Manager 267-685-2410 | 609-238-6147 jcarson@vetlearn.com Russell Johns Associates, LLC Classified Advertising Market Showcase 800-237-9851 | vetforum@rja-ads.com DESIGN Michelle Taylor, Senior Art Director 267-685-2474 | mtaylor@vetlearn.com David Beagin, Art Director 267-685-2461 | dbeagin@vetlearn.com Bethany Wakeley, Production Artist Stephaney Weber, Production Artist OPERATIONS Marissa DiCindio, Director 267-685-2405 | mdicindio@vetlearn.com Elizabeth Ward, Production Manager 267-685-2458 | eward@vetlearn.com Christine Polcino, Traffic Manager 267-685-2419 | cpolcino@vetlearn.com CUSTOMER SERVICE 800-426-9119, option 2 | info@vetlearn.com PUBLISHED BY

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Editorial Board ANESTHESIOLOGY Donald C. Sawyer, DVM, PhD, DACVA Janyce Seahorn, DVM, MS, DACVA, DACVIM, DACVECC AVIAN Peter Sakas, DVM, MS BEHAVIOR Debra Horwitz, DVM, DACVB Wayne Hunthausen, DVM Gary Landsberg, BSc, DVM, DACVB

NEUROLOGY Ronald O. Schueler, DVM, DACVIM ONCOLOGY Louis-Philippe de Lorimier, DVM, DACVIM Joseph A. Impellizeri, DVM, DACVIM Gregory K. Ogilvie, DVM, DACVIM, DECVIM-CA OPHTHALMOLOGY Terri Gibson, DVM, MS, DACVO PARASITOLOGY Lora Ballweber, DVM, MS

CARDIOLOGY Andrew Beardow, DVM, DACVIM Robert Hamlin, DVM, PhD, DACVIM

PATHOLOGY Lawrence D. McGill, DVM, PhD, DACVP

DENTISTRY Jan Bellows, DVM, DAVDC, DABVP Edward Eisner, DVM, DAVDC Steven E. Holmstrom, DVM, DAVDC Heidi B. Lobprise, DVM, DAVDC Robert Wiggs, DVM, DAVDC

PHARMACOLOGY Lester Mandelker, DVM, DABVP PRACTICE MANAGEMENT Lowell Ackerman, DVM, DACVD, MBA, MPA Stephen Fisher, DVM Ronald E. Whitford, DVM

DERMATOLOGY Dawn Logas, DVM, DACVD Rosanna Marsella, DVM, DACVD Karen Moriello, DVM, DACVD

RADIOLOGY Victor Rendano, VMD, MS, DACVR Candi Stafford, RVT

EMERGENCY & CRITICAL CARE MEDICINE Nishi Dhupa, BVM, DACVECC ENDOCRINOLOGY Arnold Plotnick, MS, DVM, DACVIM, DABVP EPIDEMIOLOGY John Kaneene, DVM, PhD, MPH EQUINE MEDICINE Joseph J. Bertone, DVM ETHICS Bernard Rollin, PhD

REPRODUCTIVE PHYSIOLOGY Susan E. Piscopo, DVM, PhD SURGERY Sean Aiken, DVM, DACVS A. D. Elkins, DVM, MS, DACVS Joseph Harari, DVM, MS, DACVS Robert G. Roy, DVM, MS, DACVS Don R. Waldron, DVM, DACVS THERIOGENOLOGY Gary J. Nie, DVM, MS, PhD, DACT, DABVP, DACVIM

FELINE MEDICINE Gary D. Norsworthy, DVM, DABVP INTERNAL MEDICINE Anthony P. Carr, Dr. med. vet., DACVIM Richard B. Ford, DVM, MS, DACVIM, DACVPM (Hon) Michael R. Lappin, DVM, PhD, DACVIM Kevin Hahn, DVM, PhD, DACVIM

TOXICOLOGY Sharon Gwaltney-Brant, DVM, DABVT VETERINARY LAW Edward J. Guiducci, Esq. Elizabeth M. Hodgkins, DVM, JD

780 Township Line Road • Yardley, PA 19067 PRESIDENT Derrick Kraemer VETERINARY FORUM (ISSN 1047-6326) is published monthly by Veterinary Learning Systems, a division of MediMedia USA, 780 Township Line Road, Yardley, PA 19067. Single copy: $9.00. Payments by check must be in US funds drawn on a US branch of a US bank only; credit cards are also accepted. Periodicals postage paid at Morrisville, PA, and additional mailing offices. POSTMASTER: Send address changes to VLS, 780 Township Line Road, Yardley, PA 19067. All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright ©2009 Veterinary Learning Systems.

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August 2009 | Veterinary Forum

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AUGUST 2009

8

COVER STORY

contents

What happened to ‘recession-proof?’

Cover Image: ©2009 Shutterstock

18

F ORUM FIVE INTERVIEW Dr. Jane Brunt talks about the latest CATalyst Council news, as well as tips for a more feline-friendly practice ............................4

FORUM News

Vaccine protocols: an important part of every practice .......................6 Public health goes to the dogs .............................................................17 New pet insurance center at DogTime ................................................17 Corry installed as AVMA president ......................................................17

40

Clinical Report Products and education kill fleas ......................................14 Dr. Sophia Yin

Peer Reviewed Thoracic Radiology: Pulmonary Patterns..........................18 Dr. Michal O. Hess

DENTAL DILEMMA

Biting Be Gone....................................................................30 Dr. Jan Bellows

Business Skills also in this issue Editorial Board ......................1 Market Showcase ................38 Advertisers Index.................39 Classified Advertising..........39

Telemedicine — expert opinions just a click away .................................................................36 Paul E. Fisher

Most Unusual Case A familiar diagnosis ............................................................40 Dr. Robert C. Sartori

To receive breaking news in your inbox, visit ForumVet.com.

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Veterinary Forum | August 2009

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forum

FIVE INTERVIEW

Elevating cats with CATalyst The CATalyst Council was formed in early 2008 to help champion the cat and reverse the decline in feline visits to the veterinarian.

Jane Brunt, DVM, past president of the American Association of Feline Practitioners (AAFP) and executive director of the CATalyst Council, talks about what’s new, what’s to come and how you can make your finicky patients feel a little more welcome.

Jane Brunt, DVM

1.

The council has been around for about a year.

What has been the response from veterinarians?

The response has been fantastic. Everywhere I go, people acknowledge CATalyst and want to learn more.

Cats have been underserved from the beginning of the companion animal era of veterinary medicine.

Now, thanks to such organizations as the AAFP, American College of Veterinary Behaviorists, AAHA and AVMA, knowledgable information about feline wellness, behavior, medicine and surgery is being documented and promoted. A major purpose of CATalyst is to help drive that information further into veterinary practices to change the way veterinarians approach cat health. We also are disseminating information beyond veterinary health care teams to engage and educate animal welfare organizations and the public.

2.

What obstacles have you encountered?

Many myths, misconceptions and negative stereotypes about cats are circulating in the general public, shelters and even within the veterinary and human health care systems, and the council hopes to combat them. At times it’s like rattling a steel cage door that won’t open — we can see through it, but it stays closed.

Understanding what’s normal for cats and learning how to handle them can help make veterinary visits pleasant and something cat owners can look forward to. When a “dog person” gets beyond preconceived notions about cats, he or she understands that cats aren’t just small dogs. Cats display fascinating personalities, clever antics and “dogged” devotion to their owners.

When a veterinarian recognizes the uniqueness of cats, it can enrich the practice, educate the team, keep clients coming back and help grow the business.

3.

What’s new with CATalyst?

We recently announced the 2009 Top 10 US CatFriendly Cities and have posted the results, along with a video, on our website, www.catalystcouncil.org. It was a close race between Phoenix and Tampa, but Tampa won in the end. Also, in April we launched a newsletter that provides up-to-date information about people who promote programs about cats across the country.

4.

What should veterinarians expect from the council in the future?

We will be working with Karen Felsted, CPA, MS, DVM, CVPM, who is CEO of the National Commission on Veterinary Economic Issues, to develop cat-friendly practice tools covering feline health. The AVMA also will release a podcast on the Animal Tracks section of its website, and we are working with leaders in the shelter community to address the challenges they encounter with cats. We will continue to reach out to commercial and not-for-profit organizations that currently promote cats or should be promoting them.

5.

How can veterinarians make their practices more welcoming to cats?

It is important to recognize what can cause fear or arousal in cats, such as loud noises, unfamiliar scents and distracting visual activity, and then eliminate or mitigate those distractions or unwanted activity. Speak to cats in a calm, soothing tone and avoid the dreaded “Shhh.” To cats, it sounds like you are hissing at them.

Covering carriers and cages, putting cats into quiet examination rooms as soon as possible and having plenty of thick, soft, fuzzy examination table covers and bedding also can help. Cats deserve it, and cat owners seek it. It is good for practice morale and for the bottom line of your vF business.

— Paul Basilio

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Veterinary Forum | August 2009

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To learn how Vectra can keep clients coming back for more and your feline patients off the lunch menu, call 1-800-999-0297 or visit www.summitvetpharm.com today.

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news

Vaccine protocols: an important part of every practice

By Paul Basilio Associate Editor To help combat “option overload” when choosing which vaccinations to give patients, the American Animal Hospital Association (AAHA) and the American Association of Feline Practitioners (AAFP) offer guidelines that veterinarians can use to direct their decisions. These guidelines are divided into two major categories: core vaccines, or those that should be considered essential, and noncore vaccines, which can be considered discretionary based on the pet’s lifestyle and geographic location.

“I have the opportunity to speak with hundreds of veterinarians each year about vaccination protocols,” said Richard B. Ford, DVM, DACVIM, professor of internal medicine at the North Carolina State University of Veterinary Medicine. “Each time I address the AAHA or AAFP vaccine guidelines, I preface the discussion by stat-

ing that the guidelines are not standards. You don’t have to use them. Furthermore, the guidelines were never intended to be a universal protocol. They are simply recommendations.”

The purpose behind these guidelines, he added, is to facilitate the development of rational protocols. “As a coauthor on vaccination guidelines for 10 years, I can say that not only have the recommendations changed — new vaccines enter the market and new information about existing vaccines is published — but veterinarians’ attitudes toward the guidelines have changed as well.”

Ford explained that he has seen a trend toward accepting and implementing the AAHA and AAFP vaccine guidelines, even though practitioners may not choose to put all of the recommendations into practice. “Veterinarians are certainly paying attention,” he said, “and they are following a significant portion of the guidelines. I think that as more veterinary schools adopt the guidelines, more students will be exposed to them as well.”

Ford has heard from many veterinarians who tell him that they are not comfortable giving a vaccine just because it is licensed and available — a line of thinking that may prove advantageous. “The number of adverse reactions from a vaccination appears likely to correspond with the number of vaccinations given concurrently,” Ford said. “It has been shown that in dogs — especially small breeds — and cats, the more vaccinations you give during the same appointment, the greater the risk of an acute reaction within 3 days.”

Current issues Recent topics of interest concerning selection and use of vaccine seem to focus on Lyme disease vaccination and parvovirus vaccination.

Comments from practicing veterinarians suggest that the geoprevalence of Lyme disease may be expanding.

“I am hearing reports from veterinarians who are identifying dogs with clinical and laboratory evidence of Lyme disease in western Pennsylvania, northern California, southeastern Virginia and parts of North Carolina,” he said. “There seems to be more interest in the role of preventing Lyme disease through the use of vaccination and topical tick preventatives. Veterinarians are starting to see this disease in areas where it was unknown 10 years ago.” (continued on page 15)

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What happened to

‘recession-proof?’

By Paul Basilio • Associate Editor

In times of economic hardship, health care choices should be based on the client–practice bond, not the discount.

W

hen the bottom dropped out of the home equity market and the economy began its downward lurch, the common refrain in the veterinary industry was that the average practice would be “recession-proof” and all that would be required was a little patience and a little scrimping.

It is a couple of years into the recession now, however, and many practice owners have found themselves in a position of having to “furlough” or let go of valued employees, cut staff hours and scale back plans for growth.

Although the recession hasn’t hit the veterinary industry as hard as other industries such as the auto industry, the sacrifices are still significant.

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“People are worrying,” says Thomas E. Catanzaro, DVM, MHA, FACHE, the CEO of Veterinary Consulting International, Inc. “They are not investing as much, and they are reducing staff hours and tightening their belts.”

Such measures may not be necessary, he adds, if practices move away from linear thinking toward a more flexible, inclusive vision of team-based health care delivery.

Revenue focus “We’re seeing a drop of about 5% in vaccination revenue,” Catanzaro says. “Part of that is a result of the economy, and the other part is from the extended duration of immunity [DOI] vaccines. We began using 3-year DOI

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vaccines about 1 to 2 years ago, so the vaccine market looks a little depressed right now.”

But Catanzaro, who built and leads the largest veterinary-exclusive, diplomate-led consulting team in the United States, has client practices that have made vaccinations account for about 8% of their gross income, which has led to less of a financial crunch than in practices that focus on vaccinations. This success also derives from the National Pet Wellness Month (NPWM) program that promotes twice-yearly examinations.

“In some practices, the vaccinations have been separated from wellness visits,” he explains. “Those

of operation, only half of the veterinarians in the United States had signed up. “The clients who bought into the [NPWM] program moved from 1.9 visits per year to 3.3 visits per year,” Catanzaro says. Although the average client transaction (ACT) tends to be slightly lower, the pet is actually more valuable per year because of the increased frequency of visits.

“The challenge we have is that the industry is focused on the ACT,” he adds, which often means celebrating the sale of a 40-lb bag of dog food, for example. “The problem is that we’re putting 45% of patients on prescription diets, but fewer than 7%

“Selling

a bag of dog food makes your ACT look good, but there is no net income in it. Until practices start thinking about net instead of gross, not a lot is going to change.”

practices see the pets twice a year, run blood and urine tests and conduct surveillance and wellness care.

It works out pretty well.”

The switch from a practice focus on vaccinations and acute care runs contrary to what many veterinarians learned in school, which is to look for sick animals and fix what is wrong. “Almost everything you learn in school relates to acute care cases, but 70% of the patients coming in the door are there for wellness visits,” Catanzaro says. “If you keep looking for sick animals, you don’t get as much work.”

He notes that after the NPWM program was launched in 2004, free educational kits were sent to veterinarians who registered. After 4 years

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Veterinary Forum | August 2009

stay on it, according to Hill’s Pet Nutrition, Inc. We sell the bag to improve the ACT, but not as part of the total health care plan.”

When prescription diets are dispensed and followed up on as with a prescription drug, Catanzaro says, the clinic staff can more accurately monitor the animal’s progress.

There isn’t enough markup on most diets to justify large amounts of veterinarian time spent on nutrition follow-ups, so dedicating staff time may be appropriate. “Selling a bag of dog food makes your ACT look good, but there is no net income in it,” he says.

“Until practices start thinking about net instead of gross, not a lot is going to change.”

This also shifts the focus of the

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veterinary visit from expensive acute care diagnostics and products to less expensive surveillance and wellness, which can build the client–practice bond. “A lot is said about marketing [to build revenue], but you cannot market diabetes, congestive heart failure or thyroid conditions,” he explains. “Veterinarians have to build a client bond with the practice, and clients will bring their pets in regularly to look for early indicators of problems.” Competing practices cannot convince a client who has a bond with another practice to switch, no matter how much of a discount is offered, Catanzaro adds.

The challenge in difficult times, however, comes back to the vaccination decision. When a rabies vaccination is due, for example, clients who are not “bonded” to a clinic will choose the least expensive option; to most clients, a vaccination is a vaccination. “In-

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Surviving with Two Doctors In a traditional two-doctor practice, there will be two examination rooms, with one doctor in each. This is not the best idea.

It is better to have one doctor scheduled for outpatient visits who handles both exam rooms, and one who handles inpatient appointments and surgeries. In the middle of the day, they should swap.

If you know that you’re going from outpatient to inpatient, your day-admit rate for patients that have tougher problems is going to increase because you know you can finish up your own cases. The doctor that does surgery in the morning will then be able to talk to clients and discuss follow-up needs in the afternoon when it is time to discharge the patient. That system, augmented with staff time for basic rechecks and behavior and nutrition consults, will keep both examination rooms busy with only one doctor working up front.

— Dr. Thomas E. Catanzaro

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stead of [leveraging staff time] to offer vaccinations at appropriate prices, some practices bundle the vaccination with the consultation and escalate the price. The client then switches to another clinic, the pet meets the state requirements, and the practice [that lost the vaccination business] won’t see the pet again until it’s sick.

The dollar is going to make the choice instead of the bond. Practices that marketed heavily and tried to sell a cheaper product than the next clinic taught their clients to look for the next clinic.”

“You can’t leverage

your time enough when everything is linear — clinics need to multitask.”

The client–practice bond also can help with business in the examination room. Most companion animals are viewed as family members or friends these days, and most clients want to do the right thing for their pets. If the client makes treatment decisions based on cost and the veterinarian gives two or three treatment options separated by cost, the client will likely choose the least expensive path. A different way of coming to a treatment decision, Catanzaro says, is to tell the client what the animal needs and then shut up and listen. “We use the word ‘recommend,’” he says. “That is a leftover production term from a time when veterinarians dealt with producers who knew their own stock. Pet owners are not good at husbandry, in general, and they don’t know what is needed. If you change the word ‘recommend’ to ‘need,’ clients can hear the sense of urgency and it makes a difference.”

Team-based and growing “Veterinary technicians are trying to become more specialized, and I’m proud of them for that,” Catanzaro says, “but now we have to get the doctors to listen. The practices that do well and feel the minimum impact are the ones that use staff effectively.”

In human medicine, many doctors’ offices require a lot of preliminary time with a staff member, such as a dental hygienist or nurse, before seeing the doctor, but Catanzaro says that veterinary medicine hasn’t quite figured out how to do that yet. “The Veterinary Emergency and Critical Care Society [VECCS] has one of the great-

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est triage nursing programs, and they credential their nurses in critical care and triage,” he explains. “General practices need triage nurses. When a critical care patient comes through the door, there needs to be someone who can handle it in real time without pulling the doctor away from surgery or appointments.”

Catanzaro compares triage nurses in a veterinary clinic to emergency medical technicians (EMTs) who respond to emergency calls in ambulances. “There are no doctors in the ambulance,” he says. “Trusting human life to EMTs comes after 10 weeks of training. Our technicians have 3 years of training, but some doctors don’t trust them yet. We are seeing real resistance because managers feel they will lose the doctor-centered practice, but the idea of a doctor-centered practice is dying. You can’t leverage your time enough when everything is linear — clinics need to multitask.”

One look inside an average human dental practice reveals three or four restorative chairs and six to eight hygiene chairs per dentist. “The American Dental Association decided a long time ago that if practices keep patients coming in for $120 cleanings, the patients will come back for restorative and surgical appointments that may cost upwards of $1,000. There are two price lists, one for wellness care with a hygienist and one for the doctors. They have been able to bond people to dental practices with that technique.”

Growth in Small Times I have a client in Stockton, Calif., which has the worst home-foreclosure rate in the state, and his growth has dropped from 25% to 20%. Almost no one else in his town is growing at all, but I helped him incorporate a good wellness program, leverage staff time with clients, and create a good foundation for team-based health care.

You can deliver a lot of client contacts with staff and keep clients coming back for small “bites“ that don’t cost them a lot. Nutrition counseling, for instance, is usually given away as a free nursing consult because the client ends up buying food. Dental rechecks should be free, because you end up bringing the client back in for a dental appointment for their pet. I recommend charging a small amount for behavior consults with staff members. For semi-annual life cycle consults, surveillance lab work should be conducted. The staff can then draw sequential lab samples for any atypical findings, but hopefully the tests will be negative and you can celebrate that with the client. If you find something on the tests, then you work out a care program.

The staff can help with all of that. All of those blood and urine draws shouldn’t cost the client the price of a visit with the doctor. If you provide good care, that is all the client will want. The only thing we sell is peace of mind.

— Dr. Thomas E. Catanzaro

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The protectionism of limiting staff involvement in the delivery of veterinary health care is detrimental, Catanzaro warns, and it is one of the reasons he is organizing a team-based continuing education (CE) program at the Wild West Veterinary Conference this October in Reno, Nev. Practices are encouraged to send a representative from each part of the clinic — receptionist, technician, doctor, manager and owner.

“You can’t get team-based change unless everyone learns together,” he says. “We’re going to give everyone an action plan. We’ll put the front desk people together, the technicians will go through 2 days of sessions with other technicians and the managers and doctors will attend general sessions. On the third day, we will bring them together as a team.”

Catanzaro will lead the first of the team sessions, and then the groups will be split into facilitative sessions.

One facilitator will join each group, and the team will combine their action programs. After another plenary session, the team will be sent back out to sequence and prioritize their plans with the facilitator. A group from Bryan Dodge’s leadership program will also attend to discuss their system. “By the time the team leaves the conference, they will have a health care delivery plan,” Catanzaro says. Registration for the sessions is still open.

For more information, visit www.wildwestvc.com. vF

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August 2009 | Veterinary Forum

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clinical REPORT

By Sophia Yin, DVM, MS (Animal Science) Column Editor Special to VETERINARY FORUM

Products and education kill fleas Many flea products have come onto the market in the past 15 years, and it can be confusing to decide which ones to administer. Despite complaints from clients that some products may not be effective, choosing one does not have to be difficult, says Michael Dryden, PhD, a veterinary parasitologist at Kansas State University College of Veterinary Medicine. “The products are highly effective,” he explains. “We have tons of supporting data. The problem lies with owners who don’t follow instructions.”

Dryden knows this better than most. He has been visiting owners’ flea-infested homes to study the efficacy of flea products for almost 20 years.

He and his veterinary students have traveled to Tampa, Fla., to collect data for clinical trials. “Florida is the flea capital of North America because it is warm and humid and the yards are mostly sand,” he says. “Sand holds moisture well, and flea larvae can easily move through it.”

During Dryden’s latest trip, he found that even with modern products nothing has changed. “We saw bad flea infestations and a lack of owner compliance,” he says.

Dryden’s students counted fleas on participating pets and placed flea traps — devices with a light that blinks at a certain frequency to attract newly emerging fleas around the home. If no fleas are found inside, the infestation is coming from the environment outside. The pets are then treated for flea infestation and the pet and home are rechecked weekly for 60 days. Infestations are controlled on every pet that is treated, Dryden says.

“We were in more than 30 homes during the last trip and will be in 90 altogether before the study is complete,” he adds. “All of the owners say that the products aren’t working, but in almost every home we found that compliance, not the drug, was the issue.”

The compliance problem One common compliance problem is that people fail to treat all the dogs and cats that come in contact with

14

Veterinary Forum | August 2009

their own. Dryden describes one example from his recent trip where the owner’s cat interacted with the neighbor’s flea-infested cat. “The neighbor’s cat comes up to the front porch every day and walks around in the shrubs and bushes, dropping 30 to 40 eggs per flea per day,” he says. “It’s a continuous source of reinfestation.”

A second simple problem is that people do not treat flea infestations long enough. “When an animal is flea infested, it can take 2 to 3 months to get the problem under control,” Dryden says. Modern products kill adult fleas and/or prevent maturation of the eggs on the pet, but the eggs already in the environment will still hatch and develop into adults if the environment is not treated.

Even if the environment is treated to speed the treatment process, Dryden says there are too many sources of fleas in the natural world. “Stray dogs, cats and opossums drop flea eggs into the environment, so people must consistently treat every pet during the flea season. Some of the homes we visited did not have carpets, but we caught one to two fleas per trap because the shaded microhabitats in the yards were infested. People do not realize that it is a major problem. Even if the indoor pets are treated several times, the animals can go into the infested yard and bring in new fleas.”

What should veterinarians do?

Dryden stressed that veterinarians have to educate the client. “The day that a veterinarian can simply sell a flea product, smile and move on are gone,” he says. “Veterinarians must provide education. Owners need to be educated and recommendations need to be reinforced each year. The intermittent approach to the products will never be effective.” vF Dr. Yin owns a behavior house call practice in Davis, Calif. Her website is www.AskDrYin.com.

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news HbVgiZg! Id\Zi]Zg#

(continued from page 6)

Recognition that canine parvovirus 2c infection is emerging among dogs living in the United States has received considerable attention lately. Parvovirus 2b has been the predominant virus in the United States for the past several years. “It should be noted, however, that parvovirus 2c is not a new virus ‘strain.’ It is merely a biological variant of parvovirus,” Ford said. “To date, the vaccines that veterinarians are using are effective against a parvovirus 2c challenge. In fact, it has been shown that all of the modified live parvovirus vaccines used in the United States provide at least a 3-year duration of immunity. The emergence of parvovirus 2c most likely represents the normal genetic drift of parvovirus.

Even though the virus has changed slightly, virulence patterns have not changed.”

Annual vs. triennial vaccination Some practices have reported a slight decline in revenue because of the switch to a triennial vaccination protocol for the core vaccines, Ford said (see page 8).

In the past, clients would generally bring their pets in for an annual round of vaccinations. Now, with the longer period between when some vaccines are due, some clients are staying home.

The issue of triennial vaccination for core vaccines can be turned into an opportunity for veterinarians, Ford said, if the practice focus shifts from the annual vaccination appointment to the annual wellness appointment. “I find that a well managed practice seems to have little difficulty bringing clients in every year,” he said. “The annual visit is good. Keep encouraging that.

If the patient needs a vaccination then give it, but conduct a physical exam and run surveillance lab tests.

Practices that operate on this basis have outstanding birth-to-death, lifestyle-oriented wellness programs and see 80% compliance rates. It drives revenue and it is best medicine.”

Practices that focus on wellness instead of an appointment centered on vaccinations are more likely to generate return business and develop a bond with clients that results in increased revenue. “Some of the practices that focus on wellness have become so successful that they can offer vaccinations to the client at cost. Some practices even offer the vaccination at no cost if the client buys into a wellness program. Best medicine happens when you look at the whole patient and its environment. The AAHA and AAFP vaccination guidelines fit into that construct very well.”

For more information on vaccination guidelines, visit www.catvets.com or www.aahanet.org. vF

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August 2009 | Veterinary Forum

15

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Easy to set up and easy to use, Vetstreet® is a powerful practice communication and management tool that keeps you in touch with your clients via Pet Portals. To discover how Vetstreet can help you increase client satisfaction, build compliance, and enhance your bottom line, visit Vetstreet.com, call toll-free 888-799-8387, or email info@vetstreet.com.

AND SIGN UP FOR OUR FREE WEBINAR. Vetstreet and Pet Portal are registered trademarks of VetInsite.com, Inc.

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news

Public health goes to the dogs The AVMA is applauding the introduction of new public health legislation that “highlights the critical role veterinarians in public and private practice have in public health and [...] recognizes the need for federal investment in bolstering the veterinary workforce, which is on the front lines of public health, food safety and animal health,” according to Ron DeHaven, DVM, AVMA chief executive officer. The bill, known as the Veterinary Public Health Education and Workforce Act, creates new programs for training veterinarians and offers additional federal support to protect public health. vF

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Insurance center at DogTime DogTime, the largest online entity in the $45.4 billion US pet market, has launched a comprehensive online pet insurance center. The center allows pet owners to compare different options using the Plan Comparison Grid, an interactive grid that compares plans side by side based on 10 criteria. The grid can be customized to compare just the plans that are relevant to a particular shopper’s needs. The website also offers guidance to pet owners through editorial content that explains key issues and concerns about pet insurance. vF

Corry new AVMA president

• Provide private pet health websites for every client • Increase compliance through automated services

SEATTLE — James Cook, DVM, officially handed over the title of American Veterinary Medical Association (AVMA) president to Larry Corry, DVM, at the 2009 AVMA Convention President’s Installation Luncheon in Seattle. Corry, a small animal practitioner from Buford, Ga., becomes the 129th president of the AVMA. Corry served 15 years in the AVMA House of Delegates, 6 years on the House Advisory Committee and 2 years on the Political Action Committee. He received his veterinary medical degree from the University of Georgia in 1966 and spent two years in the United States Air Force Veterinary Corps.

He currently owns two animal hospitals and is a stockholder and on the board of directors of three emergency clinics. vF August 2009 | Veterinary Forum

Vetstreet uses the latest technology to help you bridge the gap between client and practice. Now you can:

17

• Create a competitive online store • Educate your clients at their convenience—and yours

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peer reviewed

By Michal O. Hess, DVM

Thoracic Radiology: Pulmonary Patterns ecause interpretation of pulmonary patterns can be confusing, understanding the processes behind the patterns is important and following a step-by-step approach can simplify the process. First, the lung vasculature should be evaluated for size, shape, and visibility, followed by evaluation of the parenchyma (i.e., interstitium and alveolar space) and the bronchi. After each structure has been individually evaluated, the combination of findings and distribution patterns can be used to create a list of diagnostic differentials.1,2 When interpreting thoracic radiographs, it is important to remember that structures in the thorax can be visualized because of the presence of air in the lungs.

Therefore, if structures that can normally be visualized

B

cannot be seen on a radiograph and there is no apparent pleural disease, the presence of soft tissue opacities in the lungs, such as infiltrates or atelectases, is evidentiary. In addition, remember that because the dependent lung is always partially atelectic, the structures within the nondependent lung should be the focus of examination. If a lesion in the right lung lobe is suspected, therefore, it can be visualized better on a left lateral radiograph than on a right lateral view.

Vascular patterns Vascular patterns are produced by a change in the size and shape of the pulmonary arteries or veins. The easiest vessels to evaluate are the right cranial lobe artery and

Causes of Vascular Patterns Enlarged arteries — heartworm disease; pulmonary hypertension; left- to right-sided shunting; pulmonary thromboembolism

Abnormally small vessels — hypovolemia; pulmonic stenosis; right- to left-sided shunting; thromoboembolism; emphysema

Enlarged veins — congestive heart failure; right- to left-sided shunting; fluid overload; left atrial masses

Difficult or impossible to visualize structures — lung disease; rule out technical problems

Lateral thoracic view of a cat with feline dirofilariasis. The right cranial lobar pulmonary artery (black arrows) is larger than the vein (red arrow) and appears tortuous peripherally.

In addition, note the diffuse bronchointerstitial pattern.

Thoracic radiograph of a cat diagnosed with congestive heart failure attributed to hypertrophic cardiomyopathy. Note the prominent pulmonary veins (black arrow) and the enlarged caudal vena cava (red arrows). Also note the generalized cardiomegaly and diffuse bronchointerstitial pattern caused by concurrent respiratory disease.

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Veterinary Forum | August 2009

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peer reviewed vein because they are the least superimposed by opposite lobe vessels and other structures.1–3 The artery is dorsal on a lateral view and lateral on a ventrodorsal or dorsoventral view. The artery and vein should be nearly the same size, as well as the same size as the right fourth rib on a lateral view and the ninth rib on a ventrodorsal or dorsoventral view. However, a dorsoventral view is better than a ventrodorsal view for assessing these vessels.

Enlarged pulmonary arteries indicate current or previous heartworm disease, pulmonary hypertension, left- to right-sided shunting, or pulmonary thromboembolism. In the case of heartworm disease, the pulmonary arteries are tortuous (see Causes of Vascular Patterns).

Veins that are larger than the arteries indicate impairment of the pulmonary venous return or volume overload, most commonly venous congestion from congestive heart failure. Other causes of venous enlargement are iatrogenic fluid overload, right- to left-sided shunting, and masses that interfere with pulmonary venous return.

Smaller-than-normal vessels are seen in patients with hypovolemia, pulmonic stenosis, right- to left-sided shunting, and thromboembolism. Thromboembolism can result in either smaller or enlarged vessels, depending on its location in the pulmonary vasculature.

The lack or lessening of vascular visualization on a high-quality radiograph can result from silhouetting of the vessels, such as occurs with bronchial, interstitial, or alveolar disease (see the section Interstitial patterns).

For example, difficulty in distinguishing vessels on radiographs is a sign of early pulmonary edema. In addition, film underexposure, the presence of atelectasis, and expiration when the radiograph is taken also can result in reduced visualization of the pulmonary vessels.

Compiling a differential diagnosis and rule-outs for vascular patterns can be simplified by organizing conditions according to the interpretive findings and ruling out technical anomalies.

Interstitial patterns Interstitial patterns can be structured or unstructured. An unstructured interstitial pattern is characterized by increased lung opacity and decreased visualization of the pulmonary vessels. Interstitial infiltrates obscure the vessels (see Diffuse or Disseminated Unstructured Interstitial Patterns), and there can be a netlike reticular pattern. Unstructured patterns result from the presence of fluids, such as in cases of pulmonary edema, or from the presence of cellular infiltrates (e.g.,

Diffuse or Disseminated Unstructured Interstitial Patterns Pulmonary edema — cardiogenic or noncardiogenic Pneumonia — viral, early bronchopneumonia, or when disease resolves Diffuse pulmonary lymphosarcoma — important to recognize interstitial infiltrates Fibrosis — often seen in older dogs as a result of previous disease Rule-outs — overweight patient; underexposed film; expiration when radiograph was taken

Lateral thoracic radiograph of a cat taken a few hours after smoke inhalation during a fire. Interstitial to alveolar infiltrates, visualized as poorly marginated areas of consolidation, mainly appear in the caudal lobes. The size of the heart is normal.

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Veterinary Forum | August 2009

Ventrodorsal thoracic radiograph of a cat with chronic respiratory disease.

Decreased pulmonary vascular visualization (arrow) is a result of the diffuse interstitial pattern with a bronchial component.

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Probiotic Therapy Improves Chronic Feline Diarrhea Christy Evans Cutting, DVM Companion Animal Clinic Roseburg, Oregon

Patient: Calliope, an 11-year-old domestic short-haired cat

Therapy Plan: After her surgery, I expected Calliope to have some loose stools, but when she presented with persistent diarrhea, I felt that her digestive system needed a little help to restore its normal microflora balance. I recommended that we try Purina Veterinary Diets® FortiFlora® Feline Nutritional Supplement. I started sprinkling FortiFlora on her food each day. FortiFlora was definitely what she needed. Within the first week, she started eating more and her diarrhea resolved.

Eating has always been a challenge for Calliope; she’s very particular and will become anorectic if she doesn’t like a particular food. She’s small to begin with (6 lb), so we’re constantly watchful for any weight loss. Because Calliope’s digestive system was so delicate after surgery, maintaining her appetite was a priority for us and her owner. In addition, Calliope had lost a significant amount of weight, so we offered her a variety of commercial foods to encourage her to eat.

Outcome: Calliope really didn’t seem “better” until we started FortiFlora. Until recently, her owner was giving her the nutritional supplement daily because if she missed one dose, the diarrhea would return. After 2 years, her owner was able to discontinue FortiFlora, and Calliope is now eating well and doing great without any gastrointestinal problems!

This information has not been peer reviewed and does not necessarily reflect the opinions of, nor constitute or imply endorsement or recommendation by, the Publisher or Editorial Board. The Publisher is not responsible for any data, opinions, or statements provided herein.

©Jeannine Cook

History: In January 2004, Calliope presented with constipation. We administered two enemas and prescribed 1 mL lactulose once every 12 to 24 hours. She did reasonably well on lactulose for approximately 1 year, but the constipation returned. At this point, we increased the dose of lactulose to 1 mL every 8 hours, which worked until January 2006.

This time, the constipation didn’t respond to enemas, so we sedated Calliope for manual removal of the impacted feces. Unfortunately, she didn’t tolerate sedation well.

She became hypothermic and almost comatose; intensive care, including intravenous fluids with corticosteroids, was needed to help pull her through. She slowly improved over the next 3 days and began eating on the fourth day.

She was sent home but returned the next day with diarrhea and vomiting. I referred her owner to the nearest specialist for more involved diagnostics and treatment. Luckily they obliged—Calliope was diagnosed with an abnormal colon that required a partial colectomy 2 days later.

Calliope has had no more problems with constipation, but she developed diarrhea for 6 months following surgery.

Calliope Veterinarian’s Comments I have been recommending Purina Veterinary Diets ® FortiFlora ® as a nutritional supplement for more than 2 years. I like FortiFlora for several reasons: It’s convenient to dispense and administer, it’s easy on the GI tract, cats love the taste, and it works! Calliope’s owner really feels that FortiFlora made the difference for her cat.

I commonly use the nutritional supplement in dogs and cats that develop mild diarrhea when receiving antibiotics. It’s nice to have something to offer owners when they call with this problem, without having to change antibiotics or bring the pet back in for a recheck. I also commonly use FortiFlora for pets with stress diarrhea—It seems to work very well for these cases.

I recommend that my veterinary colleagues try FortiFlora. It’s easy to administer; you just sprinkle the nutritional supplement on the pet’s food. It works fast and is so simple and effective!

Sponsored by

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peer reviewed inflammatory, hemorrhagic, neoplastic).1,2 The differential diagnosis and rule-outs include cardiogenic and noncardiogenic pulmonary edema. With cardiogenic pulmonary edema, radiographic signs begin with pulmonary venous engorgement. Fluid leaks into the pulmonary interstitium and collects along the triad of the artery bronchus and vein, causing a peribronchial pattern — the most common sign of interstitial pulmonary edema in dogs4 — and silhouetting of the margins of the pulmonary arteries and veins (perivascular pattern). When pulmonary edema is severe, the fluid leaks into the alveolar space and air bronchograms are seen. Usually there is enlargement of the left ventricle and left atrium.

In dogs with cardiogenic pulmonary edema, the edema appears first in the central perihilar area and progresses outward. There also is a high incidence of edema in the cranioventral area on the lateral view. In cats, distribution is variable, often occurring in a patchy, irregular pattern, primarily in the caudal lobes.4 Cases of noncardiogenic pulmonary edema usually present with poorly marginated areas of consolidation and are more severe in the caudal lung lobes. The heart size is normal (see Diffused or Disseminated Structured Interstitial Patterns).

It is important to recognize cases in which the infiltrate is interstitial because the cause of lung disease can

be characterized according to the patient’s response to supportive therapy. If the patient fails to respond, lung aspiration and even lung biopsy may be necessary.

Structured interstitial patterns can be miliary (i.e., the distinct structures are smaller than 5 mm) or nodular (i.e., the structures are larger than 5 mm). Lung masses are interstitial as well. It should be noted that end-on pulmonary vessels are more numerous in the perihilar area and become smaller in diameter toward the periphery. They also are associated with linear vascular shadows and usually have considerable opacity, similar to a linear blood vessel of the same diameter.

A nodular pattern can occur with the presence of multiple nodules. In cases of metastasis, sarcomas (except for hemangiosarcoma) tend to be well defined, whereas hemangiosarcomas and carcinomas, such as thyroid carcinomas, mammary adenocarcinomas, and transitional cell carcinomas, are ill defined. Hemangiosarcomas typically metastasize diffusely, whereas other metastic tumors usually have fewer and larger nodules.

With cysts, the wall is smooth and thin; with bullae, the wall might not be evident; and with abscesses, the wall is thick with a central cavity. Cavitary neoplasms have thick, irregular walls and an eccentric cavity.4 In cats, the early stages may look like doughnuts and might be mistaken for a bronchial pattern.

Diffuse or Disseminated Structured Interstitial Patterns Miliary — granulomatous pneumonia caused by fungal infection, toxoplasmosis, or lungworms; early metastasis; end-on pulmonary vessels; pulmonary osteoma (a mineralized, more or less uniform, incidental finding) Nodular — solitary mass, including malignant primary

tumor, abscess, granuloma, and metastasis; solitary nodule, such as hematoma, or an artifact (e.g., skin nodule, nipple); multiple nodules, including hemangiosarcomas and sarcomas, as well as granulomas; cavitary nodules, including cysts, bullae, abscesses, and cavitary neoplasias

Lateral thoracic radiograph of a dog with pulmonary neoplasia. Note the well-circumscribed soft tissue opacities (arrows).

Lateral thoracic radiograph of a dog with a hemangiosarcoma.

Note the ill-defined patchy densities in the lungs, which represent metastasis.

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Veterinary Forum | August 2009

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peer reviewed Structured and unstructured interstitial patterns can present simultaneously.

Bronchial patterns Bronchial patterns result from accumulation of fluid or cells within the bronchial wall or its immediate surrounding peribronchial and perivascular connective tissue. A bronchial pattern is characterized by doughnuts and tram lines. Doughnuts are end-on airways with a thickened wall and air in the middle. They are sometimes easier to visualize on a ventrodorsal rather than a lateral radiograph. Look for them in the periphery over soft tissue structures, such as the heart or diaphragm (see Diffuse or Disseminated Peribronchial Patterns).

When seen from the sides, these airways look like tram lines, but they are more difficult to identify with this view. In areas of doughnuts, expect to see tram lines

as well. Because the bronchioles have a branching arrangement, many branches may be located in the same area but cut in different planes.1,2 Tram lines should be distinguished from paired blood vessels. Unlike blood vessels, tram lines are paired lines with a uniform width, are thinner than blood vessels, and do not taper.

It also is important to differentiate a doughnut from an end-on airway. A finding is considered to be a doughnut only if the wall is thickened. It is important to remember that bronchi are normally visualized near the heart base, where their diameter is still quite large. Normally, their walls are not visible, and they are flanked by vessels running parallel to them. Older dogs may develop mineralization of the airways and trachea, which is not a normal aging change in cats. As with a true bronchial pattern, the bronchial walls are visible further in the periph-

Diffuse or Disseminated Peribronchial Patterns Early stages of lung metastasis Interstitial pulmonary edema — see Diffuse or Disseminated Unstructured Interstitial Patterns Fungal pneumonia Early stages of cavitary neoplasia — in cats only Chronic bronchitis — allergic, such as feline asthma; infectious; irritant, such as pets that live with smokers; acute bronchitis (usually not visible on radiographs)

A

Eosinophilic bronchopneumopathy — also can be found with patchy alveolar infiltrates and occasional well-defined nodules

Lateral thoracic radiograph of a cat with chronic respiratory disease and acute onset bronchopneumonia. There is a diffuse bronchointerstitial pattern. Doughnuts are best seen over the heart. The thickening of the bronchial walls is ill defined, indicating active disease.

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B

(A) Lateral thoracic radiograph of a cat with chronic respiratory disease.

Note the marked diffuse bronchial pattern with doughnuts and tram lines. (B) Ventrodorsal thoracic radiograph of the same cat. The right middle lung lobe is consolidated, and there is a lobar sign between the right middle and right caudal lung lobes.

The black arrows indicate tram lines, which are associated with a doughnut (red arrows).

Designed for Dogs, approved for Surgery

As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, kidney or liver side effects. These are usually mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur.

Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including PREVICOX. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. Refer to the prescribing information for complete details or visit www.previcox.com. ŽPREVICOX is a registered trademark of Merial. Š2009 Merial Limited, Duluth, GA. All rights reserved. PVX08NASURGTRADEAD. See Page 26 for Product Information Summary

For more information, please call Merial Customer Service at 1-888-MERIAL-1 (1-888-637-4251), or contact your Merial Sales Representative or Merial Sales Agent Representative.

CHEWABLE TABLETS BRIEF SUMMARY: Before using PREVICOX, please consult the product insert, a summary of which follows: CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian.

CONTRAINDICATIONS: Dogs with known hypersensitivity to firocoxib should not receive PREVICOX. WARNINGS: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans.

For oral use in dogs only. Use of this product at doses above the recommended 2.27 mg/lb (5.0 mg/kg) in puppies less than seven months of age has been associated with serious adverse reactions, including death (see Animal Safety). Due to tablet sizes and scoring, dogs weighing less than 12.5 lb (5.7 kg) cannot be accurately dosed.

All dogs should undergo a thorough history and physical examination before the initiation of NSAID therapy. Appropriate laboratory testing to establish hematological and serum baseline data is recommended prior to and periodically during administration of any NSAID. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions and Animal Safety) and be given a Client Information Sheet about PREVICOX Chewable Tablets.

For technical assistance or to report suspected adverse events, call 1-877-217-3543.

PRECAUTIONS: This product cannot be accurately dosed in dogs less than 12.5 pounds in body weight. Consider appropriate washout times when switching from one NSAID to another or when switching from corticosteroid use to NSAID use.

As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal, gastrointestinal and hepatic toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/or hepatic dysfunction.

Concurrent administration of potentially nephrotoxic drugs should be carefully approached and monitored. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since NSAIDs possess the potential to produce gastrointestinal ulcerations and/or gastrointestinal perforations, concomitant use with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein bound drugs with PREVICOX Chewable Tablets has not been studied in dogs. Commonly used protein-bound drugs include cardiac, anticonvulsant, and behavioral medications. The influence of concomitant drugs that may inhibit the metabolism of PREVICOX Chewable Tablets has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. If additional pain medication is needed after the daily dose of PREVICOX, a non-NSAID class of analgesic may be necessary. Appropriate monitoring procedures should be employed during all surgical procedures. Anesthetic drugs may affect renal perfusion, approach concomitant use of anesthetics and NSAIDs cautiously. The use of parenteral fluids during surgery should be considered to decrease potential renal complications when using NSAIDs perioperatively. The safe use of PREVICOX Chewable Tablets in pregnant, lactating or breeding dogs has not been evaluated.

ADVERSE REACTIONS: Osteoarthritis: In controlled field studies, 128 dogs (ages 11 months to 15 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27mg/lb (5.0 mg/kg) orally once daily for 30 days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed adverse reactions during the study.

Adverse Reactions Seen in U. S. Field Studies Adverse Reactions

PREVICOX (n=128)

Active Control (n=121)

5 1 3 1 2 1 1

8 10 3 3 1 1 0

Vomiting Diarrhea Decreased Appetite or Anorexia Lethargy Pain Somnolence Hyperactivity

PREVICOX (firocoxib) Chewable Tablets were safely used during field studies concomitantly with other therapies, including vaccines, anthelmintics, and antibiotics.

Soft-tissue Surgery: In controlled field studies evaluating soft-tissue postoperative pain and inflammation, 258 dogs (ages 10.5 weeks to 16 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for up to two days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study.

Adverse Reactions Seen in the Soft-tissue Surgery Postoperative Pain Field Study Adverse Reactions

Firocoxib Group (n=127)

Control Group* (n=131)

5 1 1 1 1 1

6 1 1 0 0 0

Vomiting Diarrhea Bruising at Surgery Site Respiratory Arrest SQ Crepitus in Rear Leg and Flank Swollen Paw *Sham-dosed (pilled)

Orthopedic Surgery: In a controlled field study evaluating orthopedic postoperative pain and inflammation, 226 dogs of various breeds, ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group were evaluated for safety. Of the 226 dogs, 118 were given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for a total of three days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study.

Adverse Reactions Seen in the Orthopedic Surgery Postoperative Pain Field Study Adverse Reactions

Firocoxib Group (n=118)

Control Group* (n=108)

1 2** 2 1 0 9 2

0 1 3 2 1 5 0

Vomiting Diarrhea Bruising at Surgery Site Inappetence/ Decreased Appetite Pyrexia Incision Swelling, Redness Oozing Incision A case may be represented in more than one category. *Sham-dosed (pilled). **One dog had hemorrhagic gastroenteritis.

POST APPROVAL EXPERIENCE: The following adverse reactions are based on voluntary post-approval reporting and are consistent with those reported for other cyclooxygenase inhibitory NSAID class drugs. The categories are listed in decreasing order of frequency by body system.

GASTROINTESTINAL: Vomiting, anorexia, diarrhea, melena, hematemesis, hematochezia, weight loss, nausea, gastrointestinal ulceration, gastrointestinal perforation, salivation.

URINARY: Azotemia, elevated creatinine, polydipsia, polyuria, urinary tract infection, hematuria, urinary incontinence, renal failure.

HEMATOLOGICAL: Anemia, thrombocytopenia.

HEPATIC: Hepatic enzyme elevations decreased or increased total protein and globulin, decreased albumin, decreased BUN, icterus, ascites, pancreatitis.

NEUROLOGICAL / BEHAVIORAL / SPECIAL SENSE: Lethargy, weakness, seizure, ataxia, aggression, tremor, uveitis, mydriasis, nystagmus.

CARDIOVASCULAR / RESPIRATORY: Tachypnea.

DERMATOLOGICAL / IMMUNOLOGICAL: Fever, facial / muzzle edema, pruritus, urticaria, moist dermatitis.

In rare situations, death has been reported as an outcome of the adverse events listed above.

INFORMATION FOR DOG OWNERS: PREVICOX, like other drugs of its class, is not free from adverse reactions. Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance. Adverse reactions may include vomiting, diarrhea, decreased appetite, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes. Serious adverse reactions associated with this drug class can occur without warning and in rare situations result in death (see Adverse Reactions). Owners should be advised to discontinue PREVICOX therapy and contact their veterinarian immediately if signs of intolerance are observed. The vast majority of patients with drug related adverse reactions have recovered when the signs are recognized, the drug is withdrawn, and veterinary care, if appropriate, is initiated. Owners should be advised of the importance of periodic follow up for all dogs during administration of any NSAID. EFFECTIVENESS: Two hundred and forty-nine dogs of various breeds, ranging in age from 11 months to 20 years, and weighing 13 to 175 lbs, were randomly administered PREVICOX or an active control drug in two field studies. Dogs were assessed for lameness, pain on manipulation, range of motion, joint swelling, and overall improvement in a noninferiority evaluation of PREVICOX compared with the active control. At the study’s end, 87% of the owners rated PREVICOX-treated dogs as improved. Eighty-eight percent of dogs treated with PREVICOX were also judged improved by the veterinarians. Dogs treated with PREVICOX showed a level of improvement in veterinarian-assessed lameness, pain on palpation, range of motion, and owner-assessed improvement that was comparable to the active control. The level of improvement in PREVICOX-treated dogs in limb weight bearing on the force plate gait analysis assessment was comparable to the active control. In a separate field study, two hundred fifty-eight client-owned dogs of various breeds, ranging in age from 10.5 weeks to 16 years and weighing from 7 to 168 lbs, were randomly administered PREVICOX or a control (sham-dosed-pilled) for the control of postoperative pain and inflammation associated with soft-tissue surgical procedures such as abdominal surgery (e.g., ovariohysterectomy, abdominal cryptorchidectomy, splenectomy, cystotomy) or major external surgeries (e.g., mastectomy, skin tumor removal ≤8 cm). The study demonstrated that PREVICOX treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with soft-surgery. A multi-center field study with 226 client-owned dogs of various breeds, and ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group was conducted. Dogs were randomly assigned to either the PREVICOX or the control (sham-dosed-pilled) group for the control of postoperative pain and inflammation associated with orthopedic surgery. Surgery to repair a ruptured cruciate ligament included the following stabilization procedures: fabellar suture and/or imbrication, fibular head transposition, tibial plateau leveling osteotomy (TPLO), and ‘over the top’ technique. The study (n = 220 for effectiveness) demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with orthopedic surgery.

ANIMAL SAFETY: In a target animal safety study, firocoxib was administered orally to healthy adult Beagle dogs (eight dogs per group) at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated dose of 5 mg/kg, there were no treatment related adverse events. Decreased appetite, vomiting, and diarrhea were seen in dogs in all dose groups, including unmedicated controls, although vomiting and diarrhea were seen more often in dogs in the 5X dose group. One dog in the 3X dose group was diagnosed with juvenile polyarteritis of unknown etiology after exhibiting recurrent episodes of vomiting and diarrhea, lethargy, pain, anorexia, ataxia, proprioceptive deficits, decreased albumin levels, decreased and then elevated platelet counts, increased bleeding times, and elevated liver enzymes. On histopathologic examination, a mild ileal ulcer was found in one 5X dog. This dog also had a decreased serum albumin which returned to normal by study completion. One control and three 5X dogs had focal areas of inflammation in the pylorus or small intestine. Vacuolization without inflammatory cell infiltrates was noted in the thalamic region of the brain in three control, one 3X, and three 5X dogs. Mean ALP was within the normal range for all groups but was greater in the 3X and 5X dose groups than in the control group. Transient decreases in serum albumin were seen in multiple animals in the 3X and 5X dose groups, and in one control animal. In a separate safety study, firocoxib was administered orally to healthy juvenile (1013 weeks of age) Beagle dogs at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated (1X) dose of 5 mg/kg, on histopathologic examination, three out of six dogs had minimal periportal hepatic fatty change. On histopathologic examination, one control, one 1X, and two 5X dogs had diffuse slight hepatic fatty change.

These animals showed no clinical signs and had no liver enzyme elevations. In the 3X dose group, one dog was euthanized because of poor clinical condition (Day 63). This dog also had a mildly decreased serum albumin. At study completion, out of five surviving and clinically normal 3X dogs, three had minimal periportal hepatic fatty change. Of twelve dogs in the 5X dose group, one died (Day 82) and three moribund dogs were euthanized (Days 38, 78, and 79) because of anorexia, poor weight gain, depression, and in one dog, vomiting. One of the euthanized dogs had ingested a rope toy. Two of these 5X dogs had mildly elevated liver enzymes. At necropsy all five of the dogs that died or were euthanized had moderate periportal or severe panzonal hepatic fatty change; two had duodenal ulceration; and two had pancreatic edema. Of two other clinically normal 5X dogs (out of four euthanized as comparators to the clinically affected dogs), one had slight and one had moderate periportal hepatic fatty change. Drug treatment was discontinued for four dogs in the 5X group. These dogs survived the remaining 14 weeks of the study. On average, the dogs in the 3X and 5X dose groups did not gain as much weight as control dogs. Rate of weight gain was measured (instead of weight loss) because these were young growing dogs. Thalamic vacuolation was seen in three of six dogs in the 3X dose group, five of twelve dogs in the 5X dose group, and to a lesser degree in two unmedicated controls. Diarrhea was seen in all dose groups, including unmedicated controls. In a separate dose tolerance safety study involving a total of six dogs (two control dogs and four treated dogs), firocoxib was administered to four healthy adult Beagle dogs at 50 mg/kg (ten times the recommended daily dose) for twenty-two days. All dogs survived to the end of the study. Three of the four treated dogs developed small intestinal erosion or ulceration. Treated dogs that developed small intestinal erosion or ulceration had a higher incidence of vomiting, diarrhea, and decreased food consumption than control dogs. One of these dogs had severe duodenal ulceration, with hepatic fatty change and associated vomiting, diarrhea, anorexia, weight loss, ketonuria, and mild elevations in AST and ALT. All four treated dogs exhibited progressively decreasing serum albumin that, with the exception of one dog that developed hypoalbuminemia, remained within normal range. Mild weight loss also occurred in the treated group. One of the two control dogs and three of the four treated dogs exhibited transient increases in ALP that remained within normal range.

Made in Canada Marketed by: Merial LLC, Duluth, GA 30096-4640, U.S.A. 1-877-217-3543 U.S. Patent Nos. 5,981,576; 6,541,646; and 6,677,373 NADA 141-230, Approved by FDA

®PREVICOX is a registered trademark of Merial. ©2009 Merial. All rights reserved. PVX08NASURGTRADEAD.

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peer reviewed ery than usual. But mineralized bronchi can show minWhen fluid leaks into the interstitium, an interstitial eral and uniform increase in opacity and have very thin, pattern can be seen. When the amount of fluid is overzealsharp borders, whereas doughnuts and tram lines have irous and the interstitium is full, fluid leaks into the alveoregular or indistinct borders and are visible separately lar space and air is only in the bronchi. In this case, air from the vessels that run parallel to them. bronchograms can be visualized.

A bronchial pattern is seen only when the process is An air bronchogram is a complete silhouette sign of severe, but bronchial disease cannot be ruled out if the the airway’s wall. The pulmonary vessels cannot be seen in pattern is not seen. the affected area. Differentiating between air bronActive bronchial disease is characterized by illchograms and a peribronchial pattern can be confusing defined thickening of the bronchial wall, whereas inacand requires the ability to visualize the outer membrane tive healed disease is characterized by a well-defined, of the airway wall. With peribronchial patterns, because thickened, occasionally mineralized, wall. fluid collects only along the airway wall, the outside and Bronchiectasis is a specific bronchial pattern resulting inner airway walls are visible, so there is radiographic confrom an end-stage problem caused by irreversible widentrast between the airway wall and the adjacent alveoli. ing of the bronchial wall. It is often seen in patients with With air bronchograms, only the airway lumen is visible. chronic infectious airway disease. The widened bronchi Alveolar Patterns do not taper toward the peIn severe cases, a localized riphery and can be saccular in alveolar pattern can develop into a diffuse one. appearance.

The common causes of Pneumonia — bacterial, bronchial pattern are inflamviral, aspiration matory, such as bronchitis, Pulmonary edema eosinophilic bronchopneumoLung lobe torsion pathy, and asthma. A periAtelectasis bronchial pattern is a common Hemorrhage radiographic sign of interstitial Heartworm disease pulmonary edema in dogs.

When a bronchial pattern Lateral view of a dog that was hit by a car. Interstitial to alveolar lung infiltrates represent probable lung is recognized, findings from contusions. A peribronchial pattern is visible surrounding bronchoalveolar lavage and the cranial lobar bronchi. The outer airway wall is still transtracheal wash can help visible. Also noted are pneumothorax and a fracture of the humerus. achieve a definitive diagnosis.

Alveolar patterns The hallmark of the alveolar pattern is an air bronchogram, which is enhanced visualization of air in the airways/bronchi/bronchioles.

This pattern occurs when the bronchial lumen is surrounded by opaque lung as a result of accumulated fluid, atelectasis, or cellular infiltrates.

Other signs of alveolar pattern are lobar borders. An alveolar pattern can be patchy, diffuse, or localized, and the distribution can be indicative of the disease process.1,2

Ventrodorsal thoracic radiograph of a cat. The left caudal lung lobe is atelectic, and a mediastinal shift to the left is seen because of the heart shifting to the left.

Lateral thoracic radiograph of a cat with heart failure caused by dilated cardiomyopathy. Air bronchograms are visible over the heart. Note that only the lumen of the airways is visible. In addition, the cardiac silhouette is partially obscured by pleural fluid.

August 2009 | Veterinary Forum

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peer reviewed When a lung lobe is fully flooded, infiltrated, or atelectic, a lobar sign can be visualized. A lobar sign is present when a sharp line of demarcation between an opaque lung lobe and adjacent to one that is either normally aerated or near normally aerated.

As a general rule, lobar signs are not observed with cardiogenic pulmonary edema and suggest a focal process, whereas pulmonary edema is a more diffuse process.5 Bacterial pneumonia is usually evident on a cranioventral view, whereas viral pneumonia tends to be more apparent on the caudoventral view. In both cases, more than one lung lobe is usually involved. Aspiration pneumonia is typically noted in the dependent lung lobe but is determined by the animal’s position at the time of aspiration. It may involve the entire lobe or lung.

Lung lobe torsion is usually accompanied by pleural effusion. It is seen more often in dogs, usually large breeds, than in cats, and the middle right lung lobe and cranial lung lobes typically are affected.3 Atelectasis is accompanied by a mediastinal shift toward the atelectic lobe. In oblique radiographs, the heart may appear to be shifted as well. Therefore, it is important to assess the position before definitively concluding a mediastinal shift. In cats with asthma, atelectasis of the right middle lung lobe can occasionally be seen.

With hemorrhage, the distribution can change. Because hemorrhage is usually associated with trauma, fractured ribs, pneumothorax, and subcutaneous emphysema may be present. Hemorrhage also can occur as a result of coagulopathy or in the presence of a neoplasm, such as a hemangiosarcoma.

The differential diagnosis and rule-outs for alveolar patterns are varied (see Alveolar Patterns). When an alveolar pattern is recognized, bronchoalveolar lavage vF and transtracheal wash can characterize the fluid.

Reviewer Comment

This report presents a logical, stepwise approach to understanding and interpreting pulmonary patterns on thoracic radiographs. With digital imaging, the radiographs are crisper and clearer than were possible with traditional film.

References 1. Tobin E. Radiographic interpretation of pulmonary patterns. UK Vet 2004;9(4):36-39.

2. Biery DN, Owens JM. Radiographic Interpretation for the Small Animal Clinician, ed 2. Baltimore, Md.: Williams & Wilkins; 1999:156-170.

3. Ackerman L. Radiographic Diagnosis of Pulmonary Disease. In: Proceeding of the WSAVA Congress; 2002.

4. Avner A. Hyperlucent and cavitary lung lesions. UK Vet 2005;10(4):55-60.

5. O’Grady MR, O’Sullivan ML. Clinical cardiology concepts: thoracic radiology tutorial. Available at http://vetgo.com. Accessed July 2009.

Dr. Hess is affiliated with the Veterinary Clinic of East Hampton in New York.

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With the introduction of the first vaccine for canine influenza,

only the love is contagious.

Now you can provide your patients with more comprehensive protection against respiratory infection.

Love is not the only thing in the air. Canine influenza virus (CIV) has been confirmed in dogs across 30 states and the District of Columbia, and its prevalence is rising.1 And because most dogs are naive to the virus, virtually every naive dog exposed will become infected.2 CIV is highly contagious and sometimes deadly. Clinical signs associated with CIV can be confused with kennel cough making accurate diagnosis difficult. Now you can broaden the respiratory protection you currently offer to patients with the addition of the first vaccine for canine flu, Canine Influenza Vaccine, H3N8.

Canine Influenza Vaccine, H3N8 —a killed virus vaccine from Intervet/Schering-Plough Animal Health—significantly decreases clinical signs of disease and reduces viral shedding, and its safety has been confirmed in a study involving more than 700 dogs.3

Notice: This product license is conditional. As with all USDA conditionally licensed products, data submitted to the USDA supports a reasonable expectation of efficacy.

Safety was established in trials involving more than 700 dogs.

So while CIV, like love, can be easily spread and hard to identify, it no longer has to be so overwhelming. To learn more, contact your Intervet/Schering-Plough Animal Health representative, visit www.doginfluenza.com, or call our technical services team at 800-224-5318.

References: 1. Syndromic surveillance data of Cynda Crawford, DVM, PhD, University of Florida, and Edward Dubovi, PhD, Cornell University. 2. Key facts about canine influenza. CDC Website. Available at: http://www.cdc. gov/flu/canine. Accessed May 1, 2009. 3. Data on file, Intervet/Schering-Plough Animal Health.

Copyright © 2009 Intervet International B.V. All rights reserved. SPAH-VC-284:9412

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DENTAL DILEMMA

By Jan Bellows, DVM, DAVDC, DABVP Column Editor

Biting Be Gone omeo, a 4-year-old, 3.5-kg, neutered Italian greyhound, presented for chronic oral pain so severe that the dog’s owners could not approach the dog’s face without being bitten.

The dog’s teeth were cleaned and polished at 2 years of age, and semi-monthly to monthly repositol steroid injections were administered by the referring veterinarian for 1 year prior to presentation. The injections resulted in dramatic behavioral improvement that lasted 2 to 3 weeks. The referring veterinarian recommended daily oral hygiene with toothbrush and dentifrice and weekly application of a plaque preventative wax polymer. Unfortunately, the owner was unable to provide consistent oral hygiene.

Bilateral caudal vestibular mucositis, cheilitis, glossitis, and ulceration adjacent to the maxillary canines and incisors were present (Figures 1–3). Other physical ex-

R

amination findings were unremarkable. The maxillary and mandibular incisors were mobile secondary to stages 3 and 4 periodontal disease. The client was advised that a closer examination of the oral cavity was needed under general anesthesia.

Further communication with the owner included an explanation of the oral assessment, treatment, and prevention (Oral ATP) process. Recommendations for the initial preoperative laboratory testing (CBC, serum profile, and thyroid panel), anesthesia, intraoral radiography, and a tooth-by-tooth examination were accepted with the understanding that a treatment plan would be formulated and discussed after the initial assessment. The client was advised that treatment of chronic oropharyngeal inflammation typically included multiple extractions.

Laboratory test results were within normal limits. The dog was premedicated with hydromorphone at 0.1 mg/kg IM combined with acepromazine at 0.02 mg/kg IM; induced with propofol at 3 mg/kg IV; and intubated and maintained on 2% isoflurane mixed with oxygen. The body temperature was controlled with the Hot Dog patient warming system (Hot Dog USA).

Individual clinical and radiographic tooth examination revealed stages 2 and 3 mobility of the maxillary and mandibular incisors.

A recommendation for extraction of the right and left maxillary first and second incisors, canines, third and fourth premolars, first, second and third molars, and mandibular incisors was made to the owner. These extractions would be needed to relieve gingival inflammation, even in areas where the underlying radiographs appeared normal. The treatment plan was approved.

The oral cavity was irrigated with 0.12% chlorhexidine solution. Maxillary and mandibular regional blocks were accomplished with 0.2-ml injections of bupivacaine. Envelope gingival flaps were created using a #15 scalpel blade to incise vertically into the gingival sulcus circumferentially around the teeth to be extracted. A Freer periosteal elevator was used to expose the alveoli of the

Figure 1. Right maxillary buccal mucositis with ulceration.

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There has never been a better time to be accredited by the American Animal Hospital Association

AAHA is launching a $1 million dollar accreditation awareness campaign throughout the U.S. and Canada, the biggest outreach effort to the pet-owning public in our history. In the next three years you will see: • Commercials on Animal Planet (almost 200 million estimated impressions) • Sponsorship of the Animal Planet Puppy Bowl • Relocation, shelter and breeder partnerships • Co-op advertising opportunities in local markets • Much, much more: visit AAHAnet.org for details

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The time and money invested into AAHA accreditation has never offered such an outstanding return opportunity. We are building a national AAHA brand around accredited hospitals that will benefit every member who chooses to demonstrate their commitment to the standards.

Please call 800/883-6301 to join or visit AAHAnet.org to find out more about accreditation. ©2009 AAHA

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Figure 2. Glossitis.

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DENTAL DILEMMA

Figure 3. Left caudal cheilitis and mucositis.

teeth to be extracted. A #2 round carbide bur loaded on a sterile saline–-irrigated high-speed drill was used to remove the coronal aspect of the alveoli for ease of visualization and extraction. The multirooted teeth were sectioned using a #701 surgical bur to create single-rooted segments. A sharpened wing-tipped elevator was gently rotated perpendicular to the alveolar margins to help create sufficient mobility to deliver the tooth segments from the oral cavity using extraction forceps.

Alveoloplasty using a #2 carbide round bur loaded on a sterile saline– irrigated high-speed drill was performed on all exposed areas to smooth the coronal extent of the alveolus before closure. Intraoral radiographs were obtained and examined to confirm the extraction sites were free from root fragments. The incised gingiva was closed with 4-0 monocryl (Ethicon) suture using a continuous pattern. Romeo made an uneventful recovery from anesthesia. The owner was instructed to medicate with clindamycin at 15 mg/kg q12h, firocoxib at 5 mg/kg q24h, and tramadol HCl at 2 mg/kg PO q12h.

Follow-up examinations at 1 and 6 months after surgery revealed total clinical resolution of the oropharyngeal inflammation (Figures 4 and 5) and the aggressive behavior. Recommendations for home oral care

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CEforVETS.com is now CEforVetsandTechs.com—Your resource of choice for learning the most current approaches for diagnosing and treating challenging dermatology and parasitology cases. > Free, accredited CE by the most renowned authorities in dermatology and parasitology > Cytology gallery > Reference library

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DENTAL DILEMMA AVDC-Approved Classification of Oropharyngeal Inflammation Gingivitis — inflammation of the gingiva Periodontitis — inflammation of nongingival periodontal tissues (i.e., the periodontal ligament and alveolar bone) Sublingual mucositis — inflammation of mucosa on the floor of the mouth

Figure 4. Six-month progress check: right cheek teeth.

Caudal mucositis — inflammation of mucosa of the caudal oral cavity, bordered medially by the palatoglossal folds and fauces, dorsally by the hard and soft palate, and rostrally by alveolar and buccal mucosa Palatitis — inflammation of mucosa covering the hard and/or soft palate Glossitis — inflammation of mucosa of the dorsal and/or ventral surface of the tongue Cheilitis — inflammation of the lip, including the mucocutaneous junction area and skin of the lip Osteomyelitis — inflammation of the bone and bone marrow

Figure 5. Six-month progress check: right caudal vestibule inflammation resolved.

included twice-daily use of a dental wipe infused with sodium hexametaphosphate (DentAcetic Wipes, Dermapet) and application of a wax polymer (OraVet, Merial Ltd.) every other day.

Discussion This case presented many dilemmas, including the cause of Romeo’s painful mouth. Chronic ulcerative paradental stomatitis (CUPS) is a term commonly used to describe inflamed areas adjacent to teeth in the oral cavity.

The etiology is thought to be a hyperimmune reaction to plaque. Oropharyngeal inflammation is better classified by the affected anatomic areas instead of the catch-all term “CUPS,” which in some cases is not ulcerative or generalized enough to merit the term stomatitis (see sidebar).

Generally, affected dogs display unifocal or multifocal areas of oropharyngeal inflammation. The pain secondary to ulceration does not allow owners the opportunity to provide home care. Common signs include halitosis, drooling, and pain on oral examination. The exact etiology is unknown, although plaque hypersensitivity is suspected. Maltese are predisposed, but any canine breed can be affected.

Other immune-mediated diseases, such as discoid lupus, pemphigus, and bullous pemphigoid, are syndromes that may appear similar but typically affect the mucocutaneous junctions in many areas, such as the eyes, nostrils, prepuce or vulva, or anus, which Romeo’s lesions did not.

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Stomatitis — inflammation of the mucous lining of any of the structures in the mouth; in clinical use, the term should be reserved to describe widespread oral inflammation — beyond gingivitis and periodontitis — that also may extend into submucosal tissue (e.g., marked caudal mucositis extending into submucosal tissue may be termed caudal stomatitis) Tonsillitis — inflammation of the palatine tonsil Pharyngitis — inflammation of the pharynx

The second dilemma involved therapeutic options.

Conservative treatment would have involved dental scaling, polishing, application of a wax polymer plaque preventative, and twice-daily home care. The other option was extraction of the teeth opposing the inflamed areas. If the inflammation and ulceration were secondary to a reaction to plaque and calculus, then extracting the teeth in close contact with the facial, buccal, and vestibular gingiva would have been curative.

On the surface this might appear to be overkill, but in retrospect it was successful for the patient and owner.

Romeo needed to be free from pain, which was accomplished by removing those teeth. vF For more information: Holmstrom SE (guest editor). Dentistry. Veterinary Clinics of North America: Small Animal Practice 35(7). Philadelphia: WB Saunders, 2005.

Holmstrom SE, Frost P, Eisner ER. Veterinary Dental Techniques. ed 3.

Philadelphia: WB Saunders; 2004.

Verstraete FJM. Self-Assessment Color Review of Veterinary Dentistry. Ames, Iowa, Manson Publishing, London & Iowa State University Press; 1999.

Wiggs RB, Lobprise HB. Veterinary Dentistry Principles & Practice. Philadelphia: Lippincott-Raven; 1997.

Dogs don’t have teeth to spare. But up to 80% of dogs may not be getting the oral care they need. Recommend daily GREENIES® Dental Chews to control plaque and tartar buildup and help keep teeth healthy between cleanings. Because a dog’s teeth are as irreplaceable as the rest of him. Earn oral care CE credit at vet.greenies.com.

A daily dose of prevention ®/™ Trademarks © Nutro Products, Inc. 2009

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IN PRACTICE

BUSINESS SKILLS

Telemedicine — expert opinions just a click away

By Paul E. Fisher

Telemedicine — an application of clinical medicine in which medical information is transferred over a network for the purpose of consulting on remote medical procedures or examinations.

The origin of telemedicine dates back to the early 1900s, when telephones came into use. Physicians were quick to adopt the new technology for difficult case discussions with far-away specialists. In the 1950s, television moved telemedicine forward again, and by the late 1990s, the application was used heavily in human medicine as a result of high-speed Internet connections.

Telemedicine uses two forms of communication: synchronous or asynchronous. Synchronous communication takes place in real time, such as video chat or over the telephone. Asynchronous communication involves pieces of information stored in an intermediate location, such as a computer server, until another person or group of people retrieves it. Veterinary telemedicine is almost invariably asynchronous.

Veterinary medicine was quick to identify the need for telemedicine and the opportunity to connect with remote specialists in the late 1980s. Relatively inexpensive film and document scanners, digital radiography (DR) and computed radiography (CR) systems, the Digital Imaging and Communications in Medicine (DICOM) standard and reliable high-speed Internet connections have allowed telemedicine to mature as a valid practice option over the past few years. It is now a valuable service used by thousands of clinics worldwide.

The most difficult part of telemedicine can be transmitting images or data from the primary clinic to the specialist. Because few regulations exist, it is important to look for vendors that provide DICOM-compliant equipment and user-friendly applications.

There are cost-effective ways to encode and transmit images. Inexpensive film and document scanners can be used to digitize film and documents for direct transfer.

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Film can be digitized using such equipment as a digital camera and light box, inexpensive film scanners or highend volume film scanners.

Choosing the right equipment for your practice depends on the volume of images you want to digitize and how many cases you are planning to send to your telemedicine provider. Your telemedicine provider can assist you in determining what is right for your practice.

If your clinic has DICOM-compliant DR or CR imaging systems, you are already in a position to quickly and easily send your images to a telemedicine provider.

When choosing a telemedicine provider, you should consider your overall needs. Do you want telemedicine only, or do you want digital storage and access to additional services? Most telemedicine companies offer only teleradiology and telesonography services, but some companies offer multiple disciplines in addition to a secure full-featured online picture archiving and communication system (PACS) solution that allows access to images from any computer at any time.

Many clinics opt to send all their imaging studies to specialists. In this competitive market, these practitioners find that having all their images read by a board-certified specialist sets them apart from other practices. It also can increase revenue because many of the reports recommend additional tests or studies for diagnosis and treatment. The service is simple and cost-effective and can allow clinics to practice a higher quality of medicine. In essence, telemedicine allows your clinic to hire groups of specialists to practice at your clinic.

When shopping for a telemedicine provider, it is important to look for one that approaches business as a partnership with general practitioners and can provide vF your clinic with the services you need or want.

Paul E. Fisher is president of DarkHorse Medical Ventures, a Web-based telemedicine service in Carlsbad, Calif.

JOHN WAS 58 WHEN HE THOUGHT ABOUT RETIREMENT.

THEN HE THOUGHT ABOUT WHO WOULD BUY HIS PRACTICE. VCA Animal Hospitals

PLEASE CONTACT US TODAY.

For more than 20 years, VCA’s hospital purchase programs have given practice owners the freedom to live their lives with peace of mind. More than 475 hospitals in 41 states have joined the VCA family. You have worked hard to create a legacy. VCA’s goal is to continue the success you created.

Please contact us if you have a veterinary practice in excess of $1.25 million dollars in annual revenue with 3 or more veterinarians. If you are thinking of selling your practice call VCA. If your hospital is really close to an existing VCA location a merger might be right for you.

Darin Nelson Senior Vice President Development 800-550-2388 (office) 949-228-2525 (mobile) darin.nelson@vcamail.com Neil Tauber Senior Vice President 310-571-6504 (office) 310-890-0444 (mobile) neil.tauber@vcamail.com www.vcaantech.com

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38

Veterinary Forum | August 2009

Publisher’s Disclaimer: Advertising appearing in this issue does not necessarily reflect the opinions of nor constitute or imply endorsement or recommendation by the Publisher. The Publisher is not responsible for any statements or data made by the Advertiser.

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ADVERTISING

VETERINARIANS WANTED

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Located only hours from the mountains and coastlines, our busy, progressive, and expanding five-doctor practice is fully equipped and staffed by 25 highly motivated veterinarians, technicians, and lay staff. Established more than 27 years, our hospital has an excellent client base and strong emphasis on quality care. Work in a great practice environment with an excellent opportunity for career development. Competitive salary and benefits include 401(k), profit sharing, CE, and insurance. Experience preferred. Send resume to Dr. Karl B. Milliren, 303 National Highway, Thomasville, NC 27360; email tvh303@cs.com; fax 336-475-0140.

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Log in at VetRelief.com

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39

The VETERINARY FORUM Advertisers Index is provided as a service to our readers. The publisher does not assume responsibility for any errors or omissions. Listed companies advertise products and services in this issue.

most

UNUSUAL CASE

A familiar diagnosis

By Robert C. Sartori, DVM Sun Prairie, Wis.

©2009 Andy Manis

W

Dr. Sartori and one of his patients.

e are veterinarians because we love animals. But because each pet has an owner, we often are just as involved with people as with our animal patients.

One incident in particular reminds me just how intertwined veterinary medicine and human lives can be.

A well-dressed man and young girl came into the clinic with a 9-week-old black-andwhite rat terrier. “Our puppy’s eyes are bulging out, and he’s becoming cross-eyed,” the owner said. He placed the little dog on the examination table, and what he described was quite evident. I closed the puppy’s eyes and pressed on his eyelids while listening to his heart with a stethoscope. As expected, the puppy’s heart rate did not slow down.

I cleared my throat, wondering how I was going to explain the tragic problem.

“Your puppy’s fontanels are closing, and he has a condition called internal hydrocephalus. In the center of the brain are spaces called vesicles that are filling with cerebrospinal fluid…,” I started.

Before I could finish, the man said, “You don’t need to explain. Our 8-year-old daughter has the same thing. In July, she started having convulsions again because her drainage tube was blocked. We had to take her to the hospital to get her tube replaced.”

The case was a tough reminder that no matter how focused veterinarians become on an animal’s care, there is a very human side to veterinary medicine. vF

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We believe you re too good to be micromanaged. We believe in providing more resources, not taking them away. We believe a econd opinion, or third, or fourth, can make yours even stronger. We believe in getting out of the way and letting doctors be octors. We believe you own your career. We believe you went to vet school for a very furry reason. We believe people need eterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in iving you the tools you need to do your job. We believe no matter how good you are, you can always get better. We believe t xcellent doctors make excellent colleagues. We believe mentors can learn as much as mentees. We believe in saving the lives f Pets and improving the lives of vets. We believe that you should be focused on your patient, not your paperwork. We belie hat flexible hours make for refreshed doctors. We believe cats aren’t the only animals that purr. We believe we’re helping fam es along with their Pets. We We believe believe experience experience is is powerful powerful medicine. medicine. We believe in providing more resources, not takng them away. We That you’re a healer – not an administrator. yours even stronger. We believe in getting out of the way and etting doctors be doctors. We believe you own And that the right resources make good doctors great. for a very furry reason We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time aw om it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you can always g etter. We believe that excellent doctors make excellent We We believe believe you you should should look look forward forward to to work. work. mentees. We beli That your your practice practice isis part part of of who who you you are. are. be focused on your patient, not your paperwork. W n saving the lives of Pets and That elieve that flexible hours make for refreshed doctors. We But that your loved ones at home need you too. We believe we’re elping families along with their Pets. We believe you’re too good to be micromanaged. We believe in providing more resourc ot taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We believe in getting o f the way and letting doctors be doctors. We believe you own your career. We believe you went to vet school for a very furry eason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some me away from it. We believe in giving you the tools you need to do your job. We believe no matter how good you are, you c lways get better. We believe that excellent doctors make excellent colleagues. We believe mentors can learn as much as ment We believe in saving the lives of Pets and improving the lives of vets. We believe that you should be focused on your patient, ot your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’t the only animals that pu We believe we’re helping families along with their Pets. We believe you’re too good to be micromanaged. We believe in provid ng more resources, not taking them away. We believe a second opinion, or third, or fourth, can make yours even stronger. We elieve in getting out of the way and letting doctors be doctors. We believe you own your career. We believe you went to vet chool for a very furry reason. We believe people need veterinarians as much as Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in giving you the tools you need to do your job. We believe no matter h ood you are, you can always get better. We believe that excellent doctors make excellent colleagues. We believe mentors can earn as much as mentees. We believe in saving the lives of Pets and improving the lives of vets. We believe that you should b ocused on your patient, not your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’ Banfield, believeyou’re in our too veterinarians. he only animals that purr. We believe we’re helping families along with theirAtPets.

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We believe a second people. them Because at Banfield, you aren’t just opinion, o hird, or fourth, can make yours even stronger. We believe in getting out of the way and letting doctors be doctors. touching patients – you’re touching the futureWe believe ou own your career. We believe you went to vet school for a very furry reason. We believe people need veterinarians as much of medicine. s Pets do. We believe you’re better at your job when you’ve had some time away from it. We believe in giving you the tools y eed to do your job. We believe no matter how good you are, you can always get better. We believe that excellent doctors mak We’re Banfield. We believe in vets. xcellent colleagues. We believe mentors can learn as much as mentees. We believe in saving the lives of Pets and improving t ves of vets. We believe that you should be focused on your patient, not your paperwork. We believe that flexible hours make or refreshed doctors. We believe cats aren’t the only animals that purr. We believe we’re helping families along with their Pets We believe you’re too good to be micromanaged. We believe in providing more resources, not taking them away. We believe a econd opinion Visit us at banfield.net/veterinarians We believe in getting out of the way and letting doctors be doctor We believe for a very furry reason. We believe people need veterinarians as much as Pets do. We believe you’re better at your j when you’ve had some time away from it. We believe in giving you the tools you need to do your job. We believe no matter h d l b b l h ll

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Page 1

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1.

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4. (S)-methoprene prevents flea re-infestations by killing eggs and larvae, which breaks the flea life cycle.

*

6 hrs. 12 hrs. 18 hrs. 24 hrs.

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FRONTLINE® Plus

100 90 80 70 60 50 40 30 20 10

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100 90 80 70 60 50 40 30 20 10

Keeps working on flea eggs3

LASTS2

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FAST 1 *

Skin

Day 7 Day 14 Day 21 Day 28 Days after treatment *P<0.05

FRONTLINE® Plus ADVANTAGE® K9 ADVANTIX®

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For fast-acting, long-lasting flea and tick control be sure to recommend FRONTLINE Plus. ®FRONTLINE is a registered trademark of Merial. ®ADVANTAGE is a registered trademark of Bayer Healthcare. ®K9 ADVANTIX is a registered trademark of Bayer Aktiengesellschaft. ©2008 Merial Limited, Duluth, GA. All rights reserved. FLE08PBTRADE1.

1

Data on file at Merial TS-USA-28701.

McCall JW, Alva R, Irwin JP et al. Comparative efficacy of a combination of fipronil/(S)-methoprene, a combination of imidacloprid/permethrin, and imidacloprid against fleas and ticks when administered topically to dogs. J Appl Res Vet Med 2004;2(1):74-77.

3 Franc M, Beugnet, Vermots. Efficacy of fipronil - (S)-methoprene on fleas, flea egg collection, and flea egg development following transplantation of gravid fleas onto treated cats. Vet Ther 2007;285-292.

2